For many women, the prospect of returning to exercise post partum is an exciting thought. At The Injury Clinic we believe returning to exercise is important for post partum women, but we also know it is important the return is gradual and guided. Currently, there is a distinct lack of consistency when it comes to advice around returning to exercise in the post partum period.
Practitioners at The Injury Clinic feel there are three key points for all post partum women to consider in their return to exercise;
1. All post partum women will benefit from an individualised assessment of their pelvic floor function.
– This should be conducted by a Women’s Health Physiotherapist any time from 6-weeks post partum onwards.
– Usually by this point, you will have seen your midwife or obstetrician and been given ‘clearance’ to return to exercise. If not, it is likely that you will have been referred to a Women’s Health Physiotherapist for an assessment to address concerns you may have.
– This is important to ensure the appropriate management and prevention of pelvic organ prolapse, urinary incontinence and to improve sexual function.
– Even if you don’t have any signs and symptoms of pelvic floor dysfunction (which are listed below), it is still important to have your pelvic floor function assessed to ensure problems do not occur in the future.
2. High impact exercise (including running) is NOT recommended in the first 12 weeks post partum.
– Low impact exercise is recommended for a minimum of 12 weeks and until there are no signs of pelvic floor or abdominal dysfunction. This includes:
Pelvic floor exercises
Gentle introduction of body weight exercises
Appropriate abdominal exercises that have been prescribed by a physiotherapist
3. Before returning to high impact exercise, you should see a physiotherapist.
– At The Injury Clinic, we recognise that there are many changes that occur to your body during pregnancy. Unfortunately, the body does not automatically default straight back to functioning how it did pre-pregnancy. It is therefore important to see a Physiotherapist for a functional assessment to ensure your muscles (pelvic floor, abdominals, diaphragm and global muscles) are functioning effectively. This is the safest way to return to exercise and minimise the risk of injury.
SO, WHAT DOES THIS MEAN FOR ME?
Essentially, our goal at The Injury Clinic is to guide you through a gradual return to exercise and ensure you don’t get injured throughout this process. As a rough guide we feel the following is appropriate:
Stage one – approximately 0-2 weeks post delivery:
– Pelvic floor exercises (as taught by the Physiotherapist in the hospital).
– Gentle walking as tolerated. This should be for short distances with consideration of terrain (ie. flat, paved path is best to start with initially). If there is any signs or symptoms of overload (ie. increased pain or bleeding) make sure you have enough rest to allow the symptoms to settle before trailing a shorter distance on your next walk.
Stage two – approximately 2-4 weeks post partum:
– Pelvic floor exercises as above.
– Gentle walking, gradually increasing the distance walked. Be aware of any adverse signs/symptoms that might indicate you have ‘over done it’. These may include signs of pelvic floor/abdominal dysfunction (listed below), increase in pain, increase in bleeding.
– Possible introduction of low impact function exercises ie. body weight squats. This should ONLY be started if you have seen a professional (Midwife, Obstetrician of Physiotherapist) and been cleared for this type of exercise.
Stage three – approximately 4-6 weeks post partum:
– It is at this point you will usually get ‘clearance’ to return to exercise. This is when we recommend you see a Women’s Health Physiotherapist to check your pelvic floor and abdominal function.
– Continue with walking, again continuing to gradually increase the distance.
– Progressions can be made to pelvic floor and core exercises as advised by the Women’s Health Physiotherapist.
– Gentle functional exercises ie. bodyweight squats can be progressed, again at the advice of the Women’s Health Physiotherapist.
Stage four – approximately 6-8 weeks post partum:
– Scar mobilisation may be necessary if you have a scar from your delivery. Your Women’s Health Physiotherapist will be able to guide you with this if it is needed.
– Walking – by now you will be able to increase the pace and distance of your walk. Continue to be wary of any signs of overload.
– Low impact exercises – these can be expanded to include light weights similar to what you would carry during normal everyday tasks (ie. carrying your baby in its capsule). These should be guided by a Physiotherapist.
Stage five – approximately 8-12 weeks post partum:
– At this stage most women have passed through the initial stages of healing following the birth of their child (or children). While from about 8 weeks post partum many women are feeling pretty good, it is important to remember this is when the exercise rehabilitation starts.
– Women can resume swimming (if bleeding has stopped) and spinning (if comfortable sitting in the saddle).
– Walking and low intensity strengthening exercises can continue and be progressed as appropriate by your Physiotherapist.
– Pelvic floor and abdominal exercises should be progressed by either your Physiotherapist or Women’s Health Physiotherapist.
Stage six – 12 weeks postpartum and beyond:
– If you have had an uncomplicated delivery and have been able to progress through stages one-five without any significant issues or concerns, the intensity of exercise may gradually increase from around 12weeks post partum.
– If you haven’t previously, it is at this stage you should look to book an appointment with a Physiotherapist to guide your rehabilitation and return to exercise.
SIGNS AND SYMPTOMS OF PELVIC FLOOR/ABDOMINAL DYSFUNCTION
The signs and symptoms listed below are the main things we look for that indicate there may be dysfunction with the pelvic floor and/or the abdominals. This list is not extensive so there may be other things you are experiencing that are worth mentioning to your primary carer or physiotherapist.
Some signs and symptoms include:
– Leaking urine or an increased urgency to urinate.
– Inability to control bowel movements or an increased urgency.
– A heaviness/pressure/bulge/dragging in pelvic floor area.
– Pain with intercourse.
– Separated abdominal muscles and/or decreased abdominal strength and function. This may include ‘doming’ of the tummy.
– Lower back or pelvic pain.
– Ongoing or increased blood loss, particularly if this is past 8 weeks postpartum. If you do have any significant changes to your blood loss (ie. increased volume, change in colour/smell), make sure you get in touch with your primary carer.
12 WEEKS SEEMS A LONG TIME TO GET BACK INTO HIGHER IMPACT EXERCISE…
While it often seems a long time to wait before returning to higher impact exercise, there are many factors that contribute to this. It is important to remember that throughout your pregnancy your muscles have often had to change how the function and the role they perform. The post partum period 12 weeks and beyond should be thought of as a ‘retraining and rehabilitation’ period, essentially doing different exercises to strengthen muscles and remind them how they worked pre-pregnancy. Also, the potential worst-case scenarios (ie. incontinence and pelvic organ prolapse) can be significant and cause long term ongoing issues. As always, prevention is always better than a cure and it is therefore always better to have a gradual return to exercise following pregnancy and childbirth.
It is also important to remember:
– After delivery the pelvic floor is weak and injured in most women. Majority of women will need an assessment by a Women’s Health Physio to achieve an effective pelvic floor contraction.
This includes women who had a c-section.
Often women have difficulties with completely relaxing the pelvic floor which leads to early fatigue of the muscles. This can lead to just as many issues as a weak pelvic floor.
– When looking at running specifically, 1.6-2.5x bodyweight of force can be translated through the body when running. It is possible some (if not all) of these forces are translated to the pelvic floor. This is why the pelvic floor not only needs to be strong but well coordinated to achieve the level of function needed.
– Post c-section, abdominal muscle tissue and fascia will have only regained approximately 50% of its original strength at 6-weeks post partum, and 73-93% of the original strength at 6-7months post partum.
– If you are breastfeeding your baby, it is likely you will return to higher impact exercise before your child is weaned. While this doesn’t affect your ability to exercise, there are a couple of points to consider:
It is recognised that it can take up to 3-months post weaning off breastfeeding for hormone levels to return to baseline. This can be important as some women experience significantly more joint laxity than they would usually, which may put them at higher risk of injury.
Mild to moderate exercise does not affect the quality or production of breastmilk, nor is there an increase in lactic acid in the milk. While there will be an increase in lactic acid in milk after maximal exertion, there is no evidence to show that this will affect or harm the baby.
It will be important to try and time your exercise around feeds to ensure your breasts aren’t excessively full or don’t become excessively full during exercise. This is mainly from a comfort perspective.
– As always, wearing appropriate supportive clothing is important for exercise.
Your sports bra should be supportive and not compressive. Most women will need to be fitted professionally and possibly multiple times during their breastfeeding experience, particularly if they feed for longer than 6months.
Footwear – many women will experience permanent changes to their feet after having their child/children. They will potentially need to change shoes to accommodate these changes.
Sportswear/clothing – there is some evidence that demonstrates wearing supportive clothing aimed at pelvic floor support (ie. SRC shorts) can provide significant amounts of support. While this may be the case, these supportive clothing options do not mean you don’t have to do pelvic floor and abdominal strengthening exercises.
– Majority of post partum mothers will experience ongoing sleep deprivation – whether mild or severe. It is widely accepted that there is an association between sleep deprivation and increased risk of injury, lower general health and increased stress. While this is often something that cannot be improved, it is a factor that may limit recovery and performance.
At The Injury Clinic, we recommend all post partum women see a Women’s Health Physiotherapist for the assessment of their pelvic floor and abdominal function. Once you have received clearance from your midwife or obstetrician to return to exercise, an appointment with one of the Physiotherapists at The Injury Clinic would be beneficial to assess your general musculoskeletal function and to discuss your exercise goals.